Discovery Club Registration/Permissions: 2016 - 2017

Auburn United Methodist Church After-School Program

Kindergarten – 7th Grade

Name______Date of Birth______

Gender ______Name child goes by ______Grade(2016-17)______

School Attending ______Church Membership______

Address______Home Phone? ______

Father’s Name______Cell Phone ______

Father’s Employment______Work Phone______

Mother’s Name______Cell Phone______

Mother’s Employment______Work Phone______

Child resides with ______

Preferred E-mail Address(es) ______

Name(s) and age(s) of brothers sisters______

Name and phone # of persons to be called in an emergency if parents can’t be reached:

______

______

Family Doctor and Phone Number______

Does your child have allergies?______

Who has permission to pick up your child at the end of the day?______

______

______

Any other information about your child that may be helpful for us to know: ______

Please check the appropriate box: I give permission for the use of my child’s picture in AUMC publications and/or promotions, etc. – whether in print or online. YES NO

Does your child have any health, learning or behavioral issues that we may need to be aware of/ address?If so, please provide accurate and thorough information in an attached document that will be kept confidential. This information will help us provide the best care possible for your child at Discovery Club. Please understand that we are at a disadvantage in caring for your child when we haven’t been informed of their needs. Failure to disclose significant information relevant to your child’s care may be grounds for removal from the program.

Priority Enrollment Information

Do you currently have a child enrolled at Discovery Club? Yes No

Are you a member at AUMC? Yes No

Do you have children who were previously enrolled at Discovery Club? YesNo

FIELD TRIP PERMISSION

______has my permission to takeperiodic local field trips with AUMC Discovery Club. I understand that if my child does not attend the field trip it will be my responsibility to make alternate arrangements.

Parent Signature:______

MEDICAL PERMISSION

In case of an accident, and after all attempts have been made to contact parents, Auburn United

Methodist Church has permission to take______to

obtain emergency treatment.

Parent Signature:______

MEDICATION PERMISSION

Discovery Club may administer the following medication as directed:

______

______

If my child complains of a headache, earache, etc., he or she may be given:_____Tylenol _____Ibuprofen

If my child has a significant insect bite/sting, he or she may be given ______Benadryl

Parent Signature:______

Discovery Club

TRANSPORTATION AUTHORIZATION

AUBURN UNITED METHODIST CHURCH

Discovery Club has permission to pick up my child,

______,

and transport him/her to the Discovery Club After-School program at

Auburn United Methodist Church on the following days for the duration

of the 2016-17school year

(please check all that apply):

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

It is understood that transportation arrangements must be firm prior to the beginning of the school day. The school cannot take calls during the school day to finalize transportation.

Parent Signature: ______

Date: ______